Treatment of the malar region

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Victoria Vitale-Lewis, MD John Q. Owsley, MD Fred L. Hackney, MD Gordon H. Sasaki, MD Dr. Vitale-Lewis: The first patient is a 46-year-old man who has been bothered by his malar bags for as long as he can remember (Figure 1). Dr. Owsley, would you discuss the anatomic structures that produced these malar bags? How would you go about correcting them? Figure 1. This 46-year-old man has been bothered by his malar bags for all of his adult life. Dr. Owsley: The malar bag is defined by the orbital malar septum, which originates from the arcus marginalis and inserts into the skin on a line that roughly parallels the nasojugal groove, extending laterally to the outer canthus. On this man, the line of the extended nasojugal groove, which constitutes the lower border of the malar bag, can be clearly seen. The cause of the malar bag is unknown; perhaps it is caused by interference with lymphatic drainage, which in the midface is divided by the orbital malar septum. Dr. Joel Pessa's work with dye injection1,2 showed a clear line of demarcation that limits the downward descent of subcutaneous dye, similar to a sharply demarcated black eye. Probably central and lateral lymphatic drainage in the area above the septum occurs at a slower rate than caudal drainage. I do not know of a good corrective procedure. The malar bags do not respond to correction with a standard blepharoplasty. Steroid injections yield mixed results. With a patient such as this one, direct excision that treats the malar bag with an elliptical skin excision leaves a fairly faint scar that runs parallel to the nasojugal groove. Dr. Vitale-Lewis: Could you disguise this malar bag by adding fat? Dr. Owsley: I have not had very good luck with fat injections, and I do …